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t a rr <br /> rfIGFNAL STATE OF CALIFORNIA F— <br /> Eile w h DWfi WELL COMPLETION REPORT I 10 l I I <br /> Page of! <br /> Refer to Instruction Pamphlet STATE WELL NO,/STATION NO, <br /> Owners Well No. S N°' 5 6 2 2 9 8 D_ -C <br /> Date Work Began Ended LATITUDE LONGITUDE <br /> Local Permit Agency :&13 TnA e1w,')1 C6,; I I ( I I I I I I 1 1 , 1 <br /> Permit No. Permit Date <br /> r <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION { } VERTICAL _ HORIZONTAL/._....ANGLE —(SPECIFY) Name <br /> DEPTIT TO FTRt T WATER��.-..:.(Ft.) BELOW SURFACE MailingAres <br /> 11�• DESRFaceM DESCRIPTION ! I <br /> .1 Ft. to Ft. Describe material,grain size,color,etc. Cl7Y - STATE ZIP,I <br /> fff......rrr WELL LOCATION <br /> k 70 S Address u AX <br /> �' <br /> Lcity .y4 County ,.. 1 L!!k) 1'Oh'47t-fl, ell <br /> r / APN Book Page�Parcel 14 <br /> �Q _ <br /> ' Township Range XL5 Section <br /> y - <br /> Latitude NOR Longitude t WEE <br /> t DEG. MIN. SEC. DEG. MIN. SEC. <br /> ' LOCATION SKETCH ACTIVITY <br /> NORTH �^ — NEW WELL <br /> hr MODIFICATIONlREPAiFi <br /> i J- k/74 S�! f -,�e►nbly —Deepen <br /> ,I 0 i <br /> "'T )1 6? 1 t �p T Other(SPecily) <br /> DESTROY Maser ibe <br /> r. 1. �'r��W+y,t 7,`� Procedures LOG)C OG <br /> J W ! /r'tW z Under"GEOLOGICLDG <br /> " Gf 4 j�f r 1 l( I /+ PLANNED US'E(S <br /> 11 k MONITORING <br /> 7J W�(.�tjc WATER SUPPLY <br /> 0t Domestic <br /> ti <br /> ' _ Public.' <br /> f _ Irngalion <br /> E � T Industrial <br /> .a n <br /> "FEST wEL(." <br /> _,.._CATHODIC PAOTEC <br /> SOUTH TION <br /> lliustrate or Describe Distance of Well from Londa:arks OTHER(SpecPly) <br /> stwh as Roads,Buildings.Fences,Rivers,etc. <br /> PLEASE BE ACCURATE 6 COMPLETE. F <br /> DRILLING + <br /> { � 4 METHOD _____ FLUID�}f�/�—e <br /> NATER YEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC L3S` <br /> WATER LEVEL 1—(FL) & DATE MEASURED �] <br /> 1 ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING_ k6: (Feet) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft-) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) *May not he representative of a atrell'r long-term yield. <br /> DEPTH CASINGS) DEPTH ANNULAR 11ATERIa�L <br /> FROM SURFACE $ORE TYPE ✓ FROM SURFACE TYPE <br /> HOLE — INTERNAL GAUGE: SLOT SIZE <br /> DIA. ,e z <br /> MATERIAL,, CE- BEN- l <br /> z zr DIAMETER OR WALL IF ANY FILTER PACK <br /> (Inches) o� J GRADE MENT TUNI7E FILL <br /> Ft. to FE. m v c n (Inches) THICKNESS (Inches) Ft. to Ft. (_} (✓) {✓} (TYPElSiTE) <br /> 63 z <br /> ATTACHMENTS (�} CERTIFICATION STATEMENT <br /> Geologic Log <br /> 1,the undersigned,Certify that this report is complete and accurate to the best of my knowledge and betiet- <br /> ii � / <br /> ! _ X Well construction Diagram NAME, <br /> Testing, Inc. <br /> ,.('ENRCri—AAON1DRPRINTED) <br /> Geophysical Log(s) <br /> SoatWater Chemical Anelyeee 5 owe D Martinez CA 9553 <br /> ADDRE CITY STATE DP <br /> _ Other . _ 485165 <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Signed <br /> i WELL IMiLLER A D �XR)EWESEN - DATE SIGNED C-57 LICENSE NUMBER <br /> DWRIRS REV.7-9D IF ADDITIONAL SPACE 15 NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM '� <br />